Examining Differences in Recovery Outcomes between Male and Female Hip Fracture Patients: Design and Baseline Results of a Prospective Cohort Study from the Baltimore Hip Studies.

BACKGROUND: Incidence of hip fractures in men is expected to increase, yet little is known about consequences of hip fracture in men compared to women. It is important to investigate differences at time of fracture using the newest technologies and methodology regarding metabolic, physiologic, neuromuscular, functional, and clinical outcomes, with attention to design issues for recruiting frail older adults across numerous settings. OBJECTIVES: To determine whether at least moderately-sized sex differences exist across several key outcomes after a hip fracture. DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study (Baltimore Hip Studies 7th cohort [BHS-7]) was designed to include equal numbers of male and female hip fracture patients to assess sex differences across various outcomes post-hip fracture. Participants were recruited from eight hospitals in the Baltimore metropolitan area within 15 days of admission and were assessed at baseline, 2, 6 and 12 months post-admission. MEASUREMENTS: Assessments included questionnaire, functional performance evaluation, cognitive testing, measures of body composition, and phlebotomy. RESULTS: Of 1709 hip fracture patients screened from May 2006 through June 2011, 917 (54%) were eligible and 39% (n=362) provided informed consent. The final analytic sample was 339 (168 men and 171 women). At time of fracture, men were sicker (mean Charlson score= 2.4 vs. 1.6; p<0.001) and had worse cognition (3MS score= 82.3 vs. 86.2; p<0.05), and prior to fracture were less likely to be on bisphosphonates (8% vs. 39%; p<0.001) and less physically active (2426 kilocalories/week vs. 3625; p<0.001). CONCLUSIONS: This paper provides the study design and methodology for recruiting and assessing hip fracture patients and evidence of baseline and pre-injury sex differences which may affect eventual recovery one year later.

Involvement of Advanced Practice Nurse in the Management of Geriatric Conditions: Examples from Different Countries.

The increasing demand for healthcare services is placing great strain on healthcare systems throughout the world. Although the older population is increasing worldwide, there is a marked deficit in the number of persons trained in geriatrics. It is now recognized that early detection and treatment of geriatric conditions (e.g., frailty, sarcopenia, falls, anorexia of aging, and cognitive decline) will delay or avert the development of disability. At the same time, recent years have seen an increased interest and use of advanced practice nurses (APN). Models of best practices of supervision and collaboration have been promulgated by many organizations. APN's roles and scope of practice have been expanded in many countries and the quality and cost-effectiveness of healthcare systems have improved. Nevertheless, in older people, evidence of advanced practice roles remains scattered, and there is little synthesis of evidence, and therefore it is not easy to visualize the different practice models and their components. The aim of this paper is to explain the need for advanced practice nurses to manage geriatric conditions.

Improving community ambulation after hip fracture: protocol for a randomised, controlled trial.

INTRODUCTION: After a hip fracture in older persons, significant disability often remains; dependency in functional activities commonly persists beyond 3 months after surgery. Endurance, dynamic balance, quadriceps strength, and function are compromised, and contribute to an inability to walk independently in the community. In the United States, people aged 65 years and older are eligible to receive Medicare funding for physiotherapy for a limited time after a hip fracture. A goal of outpatient physiotherapy is independent and safe household ambulation 2 to 3 months after surgery. Current Medicare-reimbursed post-hip-fracture rehabilitation fails to return many patients to pre-fracture levels of function. Interventions delivered in the home after usual hip fracture physiotherapy has ended could promote higher levels of functional independence in these frail and older adult patients. PRIMARY OBJECTIVE: To evaluate the effect of a specific multi-component physiotherapy intervention (PUSH), compared with a non-specific multi-component control physiotherapy intervention (PULSE), on the ability to ambulate independently in the community 16 weeks after randomisation. DESIGN: Parallel, two-group randomised multicentre trial of 210 older adults with a hip fracture assessed at baseline and 16 weeks after randomisation, and at 40 weeks after randomisation for a subset of approximately 150 participants. PARTICIPANTS AND SETTING: A total of 210 hip fracture patients are being enrolled at three clinical sites and randomised up to 26 weeks after admission. Study inclusion criteria are: closed, non-pathologic, minimal trauma hip fracture with surgical fixation; aged ≥ 60 years at the time of randomisation; community residing at the time of fracture and randomisation; ambulating without human assistance 2 months prior to fracture; and being unable to walk at least 300 m in 6minutes at baseline. Participants are ineligible if the interventions are deemed to be unsafe or unfeasible, or if the participant has low potential to benefit from the interventions. INTERVENTIONS: Participants are randomly assigned to one of two multi-component treatment groups: PUSH or PULSE. PUSH is based on aerobic conditioning, specificity of training, and muscle overload, while PULSE includes transcutaneous electrical nerve stimulation, flexibility activities, and active range of motion exercises. Participants in both groups receive 32 visits in their place of residence from a study physiotherapist (two visits per week on non-consecutive days for 16 weeks). The physiotherapists' adherence to the treatment protocol, and the participants' receipt of the prescribed activities are assessed. Participants also receive counselling from a registered dietician and vitamin D, calcium and multivitamin supplements during the 16-week intervention period. MEASUREMENTS: The primary outcome (community ambulation) is the ability to walk 300 m or more in 6minutes, as assessed by the 6-minute walk test, at 16 weeks after randomisation. Other measures at 16 and 40 weeks include cost-effectiveness, endurance, dynamic balance, walking speed, quadriceps strength, lower extremity function, activities of daily living, balance confidence, quality of life, physical activity, depressive symptoms, increase of ≥ 50 m in distance walked in 6minutes, cognitive status, and nutritional status. ANALYSIS: Analyses for all aims will be performed according to the intention-to-treat paradigm. Except for testing of the primary hypothesis, all statistical tests will be two-sided and not adjusted for multiple comparisons. The test of the primary hypothesis (comparing groups on the proportion who are community ambulators at 16 weeks after randomisation) will be based on a one-sided 0.025-level hypothesis test using a procedure consisting of four interim analyses and one final analysis with critical values chosen by a Hwang-Shih-Decani alpha-spending function. Analyses will be performed to test group differences on other outcome measures and to examine the differential impact of PUSH relative to PULSE in subgroups defined by pre-selected participant characteristics. Generalised estimating equations will be used to explore possible delayed or sustained effects in a subset of participants by comparing the difference between PUSH and PULSE in the proportion of community ambulators at 16 weeks with the difference at 40 weeks. DISCUSSION: This multicentre randomised study will be the first to test whether a home-based multi-component physiotherapy intervention targeting specific precursors of community ambulation (PUSH) is more likely to lead to community ambulation than a home-based non-specific multi-component physiotherapy intervention (PULSE) in older adults after hip fracture. The study will also estimate the potential economic value of the interventions.

Psychotropic medication use and association with physical and psychosocial outcomes in nursing home residents.

Psychotropic medications are commonly prescribed for older adults living in long-term care settings. Use of these medications has been associated with negative functional outcomes. The purpose of this study was to describe the prevalence of psychotropic medication use among nursing home residents, and to explore the relationship of psychotropic medication use on physical and psychosocial outcomes. A secondary data analysis was done using baseline measures from the Res-Care Intervention Study. The sample included 419 residents from 12 nursing homes. There were 288 participants (69%) who were prescribed at least one psychotropic medication, with 81 participants (19%) receiving antipsychotics, 248 (59%) receiving antidepressants, 50 (12%) receiving anxiolytics and 37 (9%) receiving sedative/hypnotics. Controlling for gender, age and cognition, physical outcomes were significantly lower in residents receiving psychotropic medications (F= 3.2, P= 0.01) compared to those not receiving psychotropic medications. Psychosocial outcomes were significantly lower in those residents receiving psychotropic mediations (F= 2.0, P= 0.04). The findings from this study provide additional support for the prevalence of psychotropic medication use among nursing home residents and suggest that residents receiving psychotropic medications may be less likely to engage in functional activities and experience decreased quality of life.

Motivating Persons with Schizophrenia Spectrum Disorders to Exercise: Rationale and Design.

Persons with schizophrenia spectrum disorders (SSDs) are not only at risk because of disabling disease symptoms but because necessary medications create health risks associated with high rates of obesity. Despite the well-known benefits of exercise, persons with SSDs rarely adhere to such regimens; few interventions to motivate exercise behavior have been tested in this group.The purpose of this study is to examine effects of the Walk, Address sensations, Learn about exercise, Cue exercise behavior for persons with SSDs (WALC-S) motivational intervention upon exercise behavior. We will recruit a total of eighty outpatients 18-68 years, meeting these criteria: 1) chart diagnosis of schizophrenia, any subtype, schizoaffective disorder or schizophreniform disorder, according to the criteria described in the Diagnostic and Statistical Manual for Mental Disorders, 2) English speaking, 3) Stable medication regimen (defined as no medication changes within the last month), and 4) medical clearance for moderate exercise in writing from primary care provider. Participants will be randomly assigned to the experimental (4-week WALC-S motivational intervention), or the control group (4-week time and attention control). After the first 4 weeks, all participants will attend a 16-week walking group.The primary measures of the effectiveness of the WALC-S are attendance, persistence and compliance to the 16-week walking group. The study will be completed in approximately January 2010. In addition to hypothesis testing, this study will provide information to estimate effect sizes to calculate power and determine appropriate sample sizes for future inquiries. This paper describes the rationale and design of the study.

Physical activity staging distribution: establishing a heuristic using multiple studies.

The purpose of this study was to identify the population prevalence across the stages of change (SoC) for regular physical activity and to establish the prevalence of people at risk. With support from the National Institutes of Health, the American Heart Association, and the Robert Wood Johnson Foundation, nine Behavior Change Consortium studies with a common physical activity SoC measure agreed to collaborate and share data. The distribution pattern identified in these predominantly reactively recruited studies was Precontemplation (PC) = 5% (+/- 10), Contemplation (C) = 10% (+/- 10), Preparation (P) = 40% (+/- 10), Action = 10% (+/- 10), and Maintenance = 35% (+/- 10). With reactively recruited studies, it can be anticipated that there will be a higher percentage of the sample that is ready to change and a greater percentage of currently active people compared to random representative samples. The at-risk stage distribution (i.e., those not at criteria or PC, C, and P) was approximately 10% PC, 20% C, and 70% P in specific samples and approximately 20% PC, 10% C, and 70% P in the clinical samples. Knowing SoC heuristics can inform public health practitioners and policymakers about the population's motivation for physical activity, help track changes over time, and assist in the allocation of resources.

Reliability and validity testing of the revised 12-item Short-Form Health Survey in older adults.

The SF-12 Short Form Health Survey was developed to describe mental and physical health status of adults, and to measure the outcomes of health care services. The purpose of this study was to test the reliability and validity of this measure in a sample of 185 older adults living in a continuing care retirement community. The mean age of the participants was 86 + 6.1 and the majority were female (82%), unmarried (82%), Caucasian (99%), and all had at least a high school education. Initial testing of the SF-12 measurement model as proposed by Ware, Kosinski, and Keller (1995) demonstrated that the model did not fit the data (chi-squared/df = 7.8). The model was revised based on modification indices and the revised model provided evidence of reliability (alpha coefficients of .70, and .89; the majority of the R2 values were greater than .50), and validity as there was improved fit of the model to the data (chi 2 difference of 123, df difference of 1.0, p < .05). There was also evidence of construct validity, based on hypothesis testing, with a statistically significant correlation between physical health and number of chronic illnesses (r = .33, p < .05) and mental health and chronic illnesses (r = .27, p < .05), and a statistically significant difference in physical health (F = 30.5, p < .05) and mental health (F = 18.5, p < .05) between those who exercise regularly and those who do not. The revised SF-12 is a reliable and valid measure of health status in independent living older adults, and has the potential for use as either a predictor or an outcome measure.

Model testing for reliability and validity of the Outcome Expectations for Exercise Scale.

BACKGROUND: Development of a reliable and valid measure of outcome expectations for exercise appropriate for older adults will help establish the relationship between outcome expectations and exercise. Once established, this measure can be used to facilitate the development of interventions to strengthen outcome expectations and improve adherence to regular exercise in older adults. OBJECTIVES: Building on initial psychometrics of the Outcome Expectation for Exercise (OEE) Scale, the purpose of the current study was to use structural equation modeling to provide additional support for the reliability and validity of this measure. METHODS: The OEE scale is a 9-item measure specifically focusing on the perceived consequences of exercise for older adults. The OEE scale was given to 191 residents in a continuing care retirement community. The mean age of the participants was 85 +/- 6.1 and the majority were female (76%), White (99%), and unmarried (76%). Using structural equation modeling, reliability was based on R2 values, and validity was based on a confirmatory factor analysis and path coefficients. RESULTS: There was continued evidence for reliability of the OEE based on R2 values ranging from .42 to .77, and validity with path coefficients ranging from .69 to .87, and evidence of model fit (X2 of 69, df = 27, p < .05, NFI = .98, RMSEA = .07). CONCLUSION: The evidence of reliability and validity of this measure has important implications for clinical work and research. The OEE scale can be used to identify older adults who have low outcome expectations for exercise, and interventions can then be implemented to strengthen these expectations and thereby improve exercise behavior.

Managing arthritis with exercise.

Almost half of all older adults have arthritis, either degenerative or inflammatory. Regular exercise is an important therapeutic intervention for all types of arthritis. Specifically, regular exercise can prevent deconditioning of the muscles, keep the joints stable, improve joint function and flexibility, decrease pain, enhance aerobic fitness, improve balance, and decrease falls. A comprehensive exercise program should include stretching exercises followed by a range-of-motion program for joints, muscle strengthening, and aerobic exercise, if possible. Unfortunately, despite these known benefits, most older adults with arthritis do not engage in regular exercise. The Seven Step Approach was developed to provide a practical framework to help overcome barriers and improve exercise activity in older adults with arthritis.

Testing a model of exercise behavior in older adults.

The purpose of this study was to test a model of exercise behavior in older adults. It was hypothesized that (a) mental and physical health directly influence self-efficacy expectations; (b) mental and physical health, age, and self-efficacy expectations influence outcome expectations; and (c) all these variables directly and/or indirectly influence exercise behavior. The sample was composed of 175 older adults living in a continuing-care retirement community, each of whom was interviewed once. Seven of the 10 hypothesized paths were significant. Physical health, self-efficacy expectations, and outcome expectations directly influenced exercise behavior, and age and mental health indirectly influenced exercise through self-efficacy expectations and outcome expectations. Combined these variables accounted for 30% of the variance in exercise behavior. To improve exercise behavior in older adults, health care providers should focus on developing interventions to strengthen self-efficacy and outcome expectations related to exercise.

Promoting health in older adults: a four-year analysis.

PURPOSE: The purpose of this study was to consider the influence of selected health promotion and disease prevention interventions in elderly residents of a continuing care retirement community (CCRC) over a four-year period by comparing actual health promotion practices of the residents. DATA SOURCES: Original research using a descriptive design, face-to-face interviews of residents (N = 176-200), chart reviews, and administration of a mini-mental state exam (MMSE) and health survey administered annually. CONCLUSIONS: In each year the mean age of the residents was at least 85, the majority were female, Caucasian, and unmarried. With the exception of checking stools for occult blood, there was a statistically significant change in all health promotion behaviors over the four-year period. The most significant change was in the area of exercise behavior, which increased from 24% of the residents participating in regular exercise in year one to 61% by year four. IMPLICATIONS FOR PRACTICE: The purpose of health promotion and disease prevention in older adults is to reduce the potential years of life lost in premature mortality and ensure better quality of remaining life. In addition to regularly scheduled interventions (group education, on-site administration of pneumonia and flu vaccines, on-site exercise room and walking group), individualized counseling regarding the pros and cons of health-promotion activities was provided to help residents make an educated decision about engaging in these activities. These interventions can be used to help facilitate participation in health promotion activities as appropriate and desired for each older adult.

Partners for NP education: the 1999 AANP preceptor and faculty survey.

PURPOSE: To increase understanding of national trends in nurse practitioner (NP) clinical education, the Education Committee of the American Academy of Nurse Practitioners (AANP) conducted a survey at the 1999 National AANP Conference in Atlanta. DATA SOURCES: A convenience sample of preceptors (n = 87) and faculty (n = 42) out of the total attendance of 1,744 responded to a written questionnaire. CONCLUSIONS: Preceptor respondents provided data concerning the number of NP students supervised, influence of student supervision on productivity, and availability of incentives for precepting. Faculty reported placement and supervision issues, the extent of precepting in their clinical practice site, and recognition and support for this role. Faculty and preceptors disagreed about the types and number of incentives offered for accepting students as well as the congruence of clinical teaching activities and national teaching guidelines. Precepting did not appear to strongly influence preceptor productivity. External funding did not influence opportunities for clinical education. IMPLICATIONS FOR PRACTICE: In 1998, the graduates of NP programs rose by 15.8% and over half of all nursing students enrolled in graduate nursing programs were seeking a NP education. This increase in students may compromise the ability of schools of nursing to insure quality clinical education of NP students by increasing faculty workload and placing greater demands on expert preceptors in the community. Clinical education is also changing in light of changes in the health care system.

Simplified scoring and psychometrics of the revised 12-item Short-Form Health Survey.

The 12-item Short-Form Health Survey was developed to describe mental and physical health status of adults and to measure the outcomes of healthcare services. Based on testing of the original SF-12 with a group of older adults, a revised scoring system and measurement model of the SF-12 Health Survey was proposed. The purpose of this study was to test the reliability and validity of this revised measurement model and scoring system. Testing was done with a sample of 187 older adults in a continuing care retirement community and a sample of 211 older adults discharged from an acute care setting. There was sufficient evidence for the internal consistency of the revised SF-12 (Cronbach alpha coefficients of 0.72 to 0.89); test retest reliability (r = 0.73-0.86); reliability based on R2 values; and validity based on confirmatory factor analysis, contrasted groups, and hypothesis testing. The revised SF-12 is a valid and reliable measure that can be used with confidence to measure outcomes for older adults.

End-of-life treatment preferences among older adults.

With the advancement of medical technology, various life-sustaining treatments are available at the end of life. Older adults should be encouraged to establish their end-of-life treatment preferences (ELTP) while they are physically and mentally able to do so. The purpose of this study was to explore ELTP among older adults and to compare those preferences in a subset of individuals who had reported their ELTP in a survey completed the previous year. This was a descriptive study of 191 older adults living in a continuing care retirement community. Approximately half of the participants did not want cardiopulmonary resuscitation, to be put on a respirator, or to receive dialysis. The findings in this study suggest that many older adults do not want aggressive interventions at the end of life, but choose rather those measures that will keep them comfortable. Moreover, treatment choices may change over time. Health care providers should initiate discussions about ELTP at regular intervals (yearly) to assist older adults in dictating their end-of-life care.

Homebound older adults' experiences with the Internet and e-mail.

The purpose of this study was to explore homebound older adults' experiences with the Internet and e-mail employing the Dutch phenomenological approach. A sample of 5 homebound older adults was included. All participants were interviewed twice. Data were analyzed employing the technique recommended by Dutch phenomenologists. The analysis resulted in a total of 10 shared themes and a thick description of the homebound older adults' experiences with the Internet and e-mail. The findings indicated that all participants were faced with various challenges in learning the Internet and e-mail. Those difficulties, however, were overcome by continuous practice and support from various sources. Ultimately they found that the Internet and e-mail were excellent sources of support and enjoyment, resulting in an improved quality of life.

Measurement of activity in older adults: reliability and validity of the Step Activity Monitor.

The purpose of this study was to test the reliability and validity of the Step Activity Monitor (SAM) when used with older adults. A total of 30 subjects with a mean age of 86 +/- 6.1 participated in the study. Sixty one-minute walks were measured with the SAM, and two observers visually counted steps. Four participants wore the SAM for 6 to 48 hours and maintained activity diaries. The intraclass correlation for the SAM recordings was R = .84. There was an overall step counting accuracy of 96%. The diaries supported the SAM data for those who wore the SAM for extended periods. The SAM is an easy to use, comfortable, valid, and reliable measure of activity in older adults and particularly may be useful to triangulate measurement of activity in these individuals.

A prediction model of aerobic exercise in older adults living in a continuing-care retirement community.

OBJECTIVES: The purpose of this study was to test a model of exercise behavior in older adults. It was hypothesized that gender, marital status, chronic illness, mental and physical health, self-efficacy and outcome expectations, fear of falling, and past exercise behavior were directly and/or indirectly associated with current exercise behavior. METHODS: In this descriptive study, interviews were conducted with 201 older adults living in a continuing-care retirement community. RESULTS: Twelve paths were significant, and the model accounted for 40% of the variance in exercise behavior. Self-efficacy expectations, outcome expectations, and prior exercise were directly associated with current exercise; health status, gender, and marital status were indirectly associated with current exercise behavior through self-efficacy and outcome expectations. DISCUSSION: Recognizing and treating mental and physical health problems may directly influence self-efficacy and outcome expectations related to exercise. Moreover, interventions that strengthen self-efficacy and outcome expectations related to exercise may improve exercise behavior.